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Based on observation, review of record, and interview, the Governing Body failed to:

A. ensure patients were cared for in a safe setting.

1. identify that bathroom doors installed in all patient rooms posed a ligature risk at the hinge pinch point.

The deficient practices identified above were determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

2. ensure adequate monitoring of patients in the admissions waiting room while unsecured, live electrical outlets were accessible to psychiatric patients seeking admission.

3. a. have an effective process for contract staff to enter and exit the facility.
b. protect vulnerable patients from potential life threatening situations from unidentified individuals, entering the facility, with free access to all patients in 3 (unit 200, unit 300-400, unit 500-600) out of 3 patient care areas.

Cross Refer to Tag A0115


B. 1. ensure the Infection Control Officer had the experience and training to lead and direct the Infection Control Program.


2. ensure the Infection Control Program was implemented and followed according to the Infection Control Plan.


3. ensure the hospital maintained a sanitary environment to ensure patient's health and safety in 7 (Main hallway leading to Unit 200, Unit 200, Main hallway leading to Unit 300 and 400, Unit 400, Unit 500, Admissions, Main lobby, Dietary/Kitchen, Laundry Room, and Assessment Room #4) of 11 areas observed.

Cross Refer to Tag A0747



C. 1. Follow physician orders for the administration of medications and failed to notify physician in 1 (12) of 4 (7, 12, 31, and 35) patient charts reviewed.

2. have any physician, nursing assessment, or interventions concerning Patient #12's pain, discomfort, or inflammation of breast, and failed to assess and reassess after vomiting. The facility failed to supply the patient with medical equipment needed to assist with breast pumping. There was no further documentation that the patients baby was followed up on or if the baby was safe and able to get nutrition. Nursing had no further documentation of the patient's breast or if the patient was having any complications in 1 (12) of 1 (12) patient charts reviewed of nursing mothers.

3. assess and reassess patients after a physical hold or restraint, administration of a chemical restraint, a fall with injury after the administration of a chemical restraint, monitor an injured patient in seclusion, assess the patient before discontinuation of seclusion and failed to assess/monitor the patient after release from seclusion in 3 (7, 31, and 35) of 4 (7, 12, 31, and 35) patient charts reviewed.

Cross Refer to Tag A0385



D. follow hospital policy for accepting verbal orders in 2 (Patient #21 and Patient #24) of 2 instances of observed verbal orders. Nursing Staff failed to read the orders back to the physician as written to ensure they were written correctly and to decrease the risk of patients being harmed by an incorrect order.

Cross Refer to Tag A0385


E. 1. ensure the hospital had an organized respiratory services department that provided respiratory services to all patients.

2. ensure respiratory care services were integrated into the hospital QAPI, (Quality Assessment Performance Improvement) program.

3. appoint a qualified MD/DO as the respiratory care services director.

4. ensure respiratory care orders were documented in the patient's record in accordance with facility policy.

5. ensure respiratory services were delivered according to facility policy.

6. ensure staff providing respiratory services were qualified and trained.

Cross Refer to Tag A1151

Based on review of records, observation, and interview, the facility failed to:



A.
1. identify that bathroom doors installed in all patient rooms posed a ligature risk at the hinge pinch point or potential self-harm risk due to removable magnets.

The deficient practices identified above were determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

2. ensure adequate monitoring of patients in the admissions waiting room while unsecured, live electrical outlets were accessible to psychiatric patients seeking admission.

3. a. have an effective process for authorized contract staff to enter and exit the facility.

b. protect vulnerable patients from potential life threatening situations from unidentified individuals, entering the facility, with free access to all patients in 3 (Unit 200, Unit 300-400, Unit 500-600) out of 3 patient care areas.

4. a. ensure nursing documented or obtained a physician's order to decrease the level of observation for suicide precautions. Failure to identify the correct suicide precautions and clear communication for monitoring a suicidal patient could lead to potential patient harm in 1(33) of 4 (7,31,33 and 35) charts reviewed.

b. ensure staff failed used safe techniques for patient holds and transfers. Risk Management failed to implement a plan to ensure staff was following safe techniques. Failure to use proper techniques could cause harm and potential injury to a patient in a mental health crisis in 3 (7,35, and 31) of 4 (7,31,33 and 35) charts reviewed.

c. ensure nursing assessed and reassessed patient's after a physical hold or restraint, administration of a chemical restraint, a fall with injury after the administration of a chemical restraint, monitor an injured patient in seclusion, assess the patient before discontinuation of seclusion and failed to assess/monitor the patient after release from seclusion in 3 (7,31, and 35) of (7,31,33, and 35) patient charts reviewed.

Refer to Tag A0144


B.
1.follow its own policy and procedures: to recognize and differentiate between a complaint and grievance, take grievances to the Grievance Committee to determine if the patient's issues were properly investigated and resolved, and failed to send quarterly reports regarding complaints and/or grievances to the Performance Improvement Committee and Governing Board.

2. failed to recognize the patients' rights to submit a written grievance, supply the materials, tools, and time needed to make a formal grievance, and failed to assist the patient through the process in 2 (#12 and #31) of 2 patient complaints reviewed and observed.

Refer to Tag A0119



C.
1. prevent neglect by providing the patients with clean clothes. Provide needed clothes to promote patient dignity and avoid mental anguish in the milieu in 1(33) of 3 (#31,#32, and #33) patient observations on the 200 Geri/psych unit.

2. provide a place for patients to sit down or lie down while being secluded. Patients were forced to sit or lie down on the floor in 3 (Unit 200, 300-400, and 500-600) out of 3 seclusion rooms.

Refer to Tag A0145

Based on review, observation and interview the facility failed to:


A. Follow physician orders for the administration of medications and failed to notify physician in 1 (12) of 4 (7, 12, 31, and 35) patient charts reviewed.

B. To have any physician, nursing assessment, or interventions concerning Patient #12's pain, discomfort, or inflammation of breast, and failed to assess and reassess after vomiting. The facility failed to supply the patient with medical equipment needed to assist with breast pumping. There was no further documentation that the patients baby was followed up on or if the baby was safe and able to get nutrition. Nursing had no further documentation of the patient's breast or if the patient was having any complications in 1 (12) of 1 (12) patient charts reviewed of nursing mothers.

C. Nursing failed to assess and reassess patient's after a physical hold or restraint, administration of a chemical restraint, a fall with injury after the administration of a chemical restraint, monitor an injured patient in seclusion, assess the patient before discontinuation of seclusion and failed to assess/monitor the patient after release from seclusion in 3 (7, 31, and 35) of 4 (7, 12, 31, and 35) patient charts reviewed.

Refer to TAG A0395

D. follow hospital policy for accepting verbal orders in 2 (Patient #21 and Patient #24) of 2 instances of observed verbal orders. Nursing Staff failed to read the orders back to the physician as written to ensure they were written correctly and to decrease the risk of patients being harmed by an incorrect order.

Tag A0407

Based on observation, record review, and interview, the facility failed to:


A. Ensure the Infection Control Officer had the experience and training to lead and direct the Infection Control Program.

Refer to Tag A0748



B. Ensure the Infection Control Program was implemented and followed according to the Infection Control Plan.

Refer to Tag A0749



C. Maintain a sanitary environment to ensure patient's health and safety in 7 (Main hallway leading to Unit 200, Unit 200, Main hallway leading to Unit 300 and 400, Unit 400, Unit 500, Admissions, Main lobby, Dietary/Kitchen, Laundry Room, and Assessment Room #4) of 11 areas observed.

This deficient practice had the likelihood to cause harm to all patients.


Findings include:


An observation tour on 1/28/2019 after 9:30 AM with Staff #8 revealed the following:

1. Main Hallway leading to Unit 200:

In the clean equipment room was a bedside commode. Under the seat of the commode were four rusted screws. Rust was noted on 4 of 4 legs and the holes where the height can be adjusted. The commode had a taped piece of paper that read, "cleaned 1/6/19 B.D." A broken walker was noted with no identifying label of being clean or dirty.

In the patient restroom, the floor around the base of the toilet was layered with dust and dirt. The inside of the hand rail was heavily covered with dust and dirt. The toilet tissue had a brown colored stain on the outside of the roll.

In the Emergency Treatment room, a dead insect was on the floor next to the wall. Exposed sheetrock was noted on the wall behind the examination table. The examination table padding divided into two parts so the head could be raised. The gap between the head and foot was heavily soiled with dust and dirt. At the foot of the examination table was a plastic strip that went from side to side. The plastic strip was torn exposing sharp edges. The rolling metal cart, that was being used for soiled linen, was rusted on the base. Rusted surfaces cannot be sanitized therefore, increasing the risk for cross-contamination between patients.

In the Oxygen Storage room, 3 empty and 7 full portable oxygen cylinders were observed. 10 of 10 oxygen cylinders were covered heavily with dust and dirt. A walk-in bath tub was stored in this room. The bath tub was soiled with heavy dirt on the inside, outside, and around the base next to the floor.


2. Unit 200:

In the Common Area, (a day room outside of patient rooms), 2 of 4 tables were missing laminate, on the sides, exposing the porous surface underneath. Porous surfaces cannot be adequately sanitized.

A ceiling vent was noted to be dusty and coated with black colored debris.

A ceiling tile was recessed back into the ceiling leaving an opening that exposed the metal frame.

Dead bugs were noted in-between the light covers and lights in 2 of 2 ceiling lights observed.

The lid on a large trash can was spoiled with brown colored liquid.

Inside the Soiled Linen room, a double sink was observed having liquid residue covering to the bottom. An unlocked cabinet above the sink, stored with new biohazard sharps containers, was visibly dirty.

Inside the Clean Linen/Supply closet was an empty 3 tier rolling metal cart. All 3 tiers were rusted. The casters were rusted and dirty. Staff #8 was asked what the cart was used for. Staff #8 said to transport clean linens when cleaning a patient room. The multi-layer shelves contained clean patient supplies. On the top shelf was a corrugated shipping box that was scuffed along the edges and dirty stored with clean items. Corrugated shipping boxes can contain insects and dirt and should not be mixed with clean supplies.

Inside the Electrical/Storage closet was a wooden wall unit with individual shelves used to store patient personal belongings and hygiene products. Some of the shelves were labeled with room numbers. On the top shelf were 6 plastic bins containing personal hygiene items. 2 of 6 bins were not labeled with patient information. On a bottom shelf was a pink laundry basket with personal clothing. This shelf had no room number on it. Cleaning supplies were also observed in this room. On the bottom shelf to the far left, a bin that contained 2 spray bottles and a scrubbing brush was noted. 1 of 2 spray bottles contained a liquid labeled "Clorox" in a black marker.

Staff #8 confirmed the findings.


3. Main Hallway leading to Unit 300 and 400:

In the restroom, the base of the toilet was covered in dust and hair. Underneath the handrail, it was noted to be soiled with heavy dirt and exposed sheet rock. Along the wall, at the baseboard, there was dirt and exposed sheetrock noted. Exposed sheetrock cannot be adequately sanitized. The door leading into the restroom had chipped paint and exposed the metal frame. With the missing paint, the door could not be adequately sanitized and increased the potential for rust and entrapment of dirt between the paint and metal frame as the paint peels.

In the medication room, outside the nursing station, was a patient nutritional refrigerator. Inside were 7 orange Gatorade bottles. 3 of 7 bottles had been opened with no patient name or date. On the top shelf (the freezer) was a green glove filled with liquid that had been frozen, an ice bag, and a "Blue Ribbon Ice Cream Sandwich." The middle shelf was soiled with a dark brown color resembling spilled liquid. The bottom had spilled orange liquid that had not been cleaned.


4. Unit 400:

In the Storage Room, used for storage of patient's personal belongings and personal hygiene products, was a wooden wall unit with shelves. The shelves were labeled with room numbers. On the shelf labeled 404B was a coffee cup, an eating utensil wrapped in a napkin, and a "Suicide Risk Assessment" packet. The shelf was visibly dusty. On the shelf labeled 407A was a plastic container that contained personal hygiene supplies with no patient name applied to the container.

Along the wall, just before the door leading into patient room #401, scuff marks, chipped paint, and exposed sheetrock was noted.

The door frame leading into patient room #401 had chipped paint and exposed the metal frame. With the missing and chipped paint, the door could not be adequately sanitized and increased the potential for rust and entrapment of dirt between the paint and metal frame as the paint peels.


5. Unit 500

Observed in patient room #505, under the mattress, the wooden platform bed was heavily soiled with dirt and debris. Around the base of the shower was a brown colored dirt that circled the entire base of the inside. The shower had an attached seat. The seat was observed to have two legs that were rusted at the base. The underside of the seat was noted to have several brown spots. Hair was on the floor of the shower next to the seat legs. Between the handrails and shower wall rust was noted. There was dirt noted on the base of the toilet on both sides. The sink was dusty and had hair on the inside.


In the Group Room, the sheetrock was separating from the floor creating a gap between the floor and the wall. Outside the group Room, on the wall above the wooden rail, were two holes with missing paint that exposed the sheetrock.

Staff #8 confirmed the findings.


Review of the hospital policies revealed the following:


Policy titled, Clinical Service Manual; Subject: Plant Operations, #1600.59 with a revised date of 1/17 revealed the following:

" ...N. Environmental Items:
3. Ceilings, walls, floors, windows and doors should be inspected regularly and kept in good repair at all times in order to maintain a clean and safe
environment ..."



Policy titled, Clinical Service Manual; Subject: Storage of Clean/Sterile Supplies; #1600.63 with a revised date of 1/17 revealed the following:

" ...C. Storage:
2. Corrugated shipping cartons must not be left in the unit storage room. Items
must be removed, inspected, and stored on shelves.

D. Shelves:
4. Shelves must be cleaned with an approved disinfectant solution on a regularly scheduled basis ..."



Policy titled, Clinical Service Manual; Subject: Departmental Cleaning; #1600.52 with a revised date of 1/17 revealed the following:


" ...A. A.M. Cleaning:
1. Equipment and furnishings, counters, table tops, appliances, and machines shall be damp-dusted with disinfectant daily at the beginning of the A.M. shift.
C. Daily Housekeeping:
1. Department equipment shall be cleaned as above by each department
personnel. Housekeeping personnel perform all other duties: Dusting,
mopping, and spot clean. Housekeeping will disinfect and sanitize furnishings, woodwork, walls, floors, doors, vents, ledges, sinks, and bathrooms according to established housekeeping procedures. Waste and trash is placed in plastic bags or puncture-proof containers as is appropriate, and removed by housekeeping personnel. Soiled linens are bagged, labeled, and sent to laundry ..."



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Assessment Room #4

In the assessment room the vital sign machine was soiled with old tape, dust and hair.

The trash cans were soiled with paper, old gum, and dried liquids.


Emergency Treatment Room
The trash can was soiled with paper and dried liquids.

The cabinet doors under the sink area was found to be unlocked. The pipes were exposed under the sink.

The cabinet drawers were full of scissors, socks, stethoscopes, seam rippers, and ID bracelets. These items were commingled with clean patient supplies.

Dirty laundry was in the hamper.


Equipment
The x-ray machine was heavily soiled with old tape residue, hair, dirt, missing paint and scratches.

Wheelchairs were found in an alcove in the hallway near unit 200. Three chairs had tags on them that said they were cleaned on 1-27-19. The chairs were found soiled with dirt, dust, dried mud on the tires, old tape residue, rust, and torn seats. One of the wheel chairs was found to have a pocket on the back of the chair. Inside the pocket a CD of a patient's chart and paper was found.


Laundry Room
In the laundry room a large hardened piece of powder detergent was found sitting uncovered in the cabinet.


Patient Room 202
In patient room 202 the mattress was found to be torn and the wooden platform was soiled with dust and hair.


Unit 200 Dayroom
The counter was sticky. The drawer handles were soiled and sticky.

The counter sink was soiled with pieces of trash and the counter was heavily soiled with a dried white substance around the sink area.

Three couches were found with trash, hair combs, paper, food, and spilled lotion under the cushions.


Unit 200 Medication room
Patient pill crushers were found stored behind the sink faucet. Water from washing hands was splattered all over the pill crushers. The sink faucet was coated in a heavy mineral deposits. The faucet was unable to be cleaned properly.

The electronic medication dispenser was heavily soiled on the outside with hair, dust and dirt.

The window in the nurse's medication room was found to be missing large pieces of paint on the metal frame.


Unit 300-400
The seclusion room on unit 300-400 was found to have heavily soiled floors of dust, dirt, and hair.

In the nurse's station on unit 300-400 was found to have heavily soiled floors. The floors were soiled with dust, dirt, and hair.
The patient medication refrigerator was soiled with hair, dust and dirt on the inside and outside.

Medication containers in the electronic medication dispensing cabinet was found to have clear medication containers with old tape, stickers, and soiled with dust.

The seventh container had a patient name written that was no longer in the facility. A Styrofoam cup was found sitting in the container. The cup held 7 different tubes of chap stick. Six of the chap sticks were found to have patient stickers on them. One of the tubes just had a patient's first name on it. Staff #5 confirmed when the patient's needed chap stick they were allowed to use the stick on their mouths return it to the nurse and it was commingled with the other chap sticks. They were then placed back into the clean medication cabinet where it could possible contaminate the other medications.

Interview with staff #13 on 1-28-19 revealed staff #13 was unable to tell the surveyor who was responsible for cleaning the nurses station and patient refrigerators. Staff #13 stated, "I would think the pharmacy but I'm not sure."

Based on Observation, record review, and interview, the facility failed to:



A. Ensure the hospital had an organized respiratory services department that provided respiratory services to all patients.


B. Ensure respiratory care services were integrated into the hospital QAPI, (Quality Assessment Performance Improvement) program.



C. Appoint a qualified MD/DO as the respiratory care services director.

Refer to tag A1153


D. Ensure respiratory care orders were documented in the patient's record in accordance with facility policy.

Refer to Tag A1164


E. Ensure respiratory services were delivered according to facility policy.

Refer to Tag 1160


F. Ensure staff providing respiratory services were qualified and trained.

Refer to Tag A1161

Based on review and interview the facility failed to:

A.) Follow its own policy and procedures: to recognize and differentiate between a complaint and grievance, take grievances to the Grievance Committee to determine if the patient's issues were properly investigated and resolved, and failed to send quarterly reports regarding complaints and/or grievances to the Performance Improvement Committee and Governing Board.

B.) The facility staff failed to recognize the patients' rights to submit a written grievance, supply the materials, tools, and time needed to make a formal grievance, and failed to assist the patient through the process in 2 (#12 and #31) of 2 patient complaints reviewed and observed.

A.) Review of the facility's policy and procedure, "Patient Grievance/Complaint" stated,
"PROCEDURE:
A. A "patient grievance" is defined as a formal, written or verbal grievance that is filed by a patient, when a patient issue cannot be resolved promptly by staff present. All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are considered grievances. Any written complaint or concern will be classified as a grievance.

A "patient complaint" is an allegation or source of dissatisfaction expressed verbally or in writing. Complaints relevant to change in bedding, housekeeping of a room, and serving preferred food and beverages are expectations that require the implementation of a relatively minor change in a timelier manner than a written response.

B. Upon request, any Hospital employee may assist a patient or their representative in the completion of a grievance letter or a Compliment/Complaint/Grievance/Suggestion form.

C. Patient Advocate will make personal contact with the patient making the request within three working days of receipt of the grievance.

1. Jointly, the patient and the Patient Advocate will discuss the patient's verbal or written request in order to clarify the patient's concerns and formulate a statement of grievance.

2. The Patient Advocate will convene a meeting with the Grievance Committee to consider the patient's grievance that are received. Composition of the Grievance Committee may include any of the following:
CEO/C00 Director of Nursing Director of Compliance Director of Clinical Services

3. The Grievance Committee will review and further investigate the substance of the patient's grievance to assist in the provision of a response and resolve any deeper, systemic problems indicated by the Grievance.

4. A written response will be provided to the patient within (7) seven working days of the initial meeting of the Advocate and the patient. The response will include:

Name of the hospital contact person.
The steps taken on behalf of the patient to investigate the grievance.
The results of the grievance process.
The date of completion.
The response will be sent by US mail, postage prepaid, to the address included in the written grievance or the address on record for the most recent patient registration. The date of mailing will be logged as the date of response.

5. If patient is dissatisfied with written response, patient care advocate will forward grievance to chief executive officer or his designee in 10 working days.

D. Grievances about situations that endanger the patient, such as neglect or abuse, shall be reported immediately to the Director of Nursing and to the Director of Risk Management.

E. The Patient Advocate and Grievance Committee must ensure that what is learned from the grievance process is forwarded to the Performance Improvement/Quality Council Committee:

1. Compliment/Complaint/Grievance/Suggestion forms are forwarded as needed to the affected department manager, CEO/COO, Director of Nursing, Director of Compliance/Risk Management, and other leaders as necessary.

2. All grievances will be logged in a database maintained at facility. The log will include patient identifiers, date of the grievance, and the date of the written response.

3. Quarterly reports regarding complaints and/or grievances are presented to the Performance Improvement Committee and Governing Board. The Performance Improvement Committee activates Task Forces, PI Teams, and ad hoc committees to investigate and resolve issues and define trends."



Review of the facility complaint/grievance log revealed there was just complaints listed. An interview was conducted with Staff #11 on 1/29/19 at 10:10AM. Staff #11 reported she did not have any grievances just complaints. Staff #11 was unaware of what changed a complaint into a grievance. Staff #11 reported she was not familiar with the facility's policy and procedure for Complaints and Grievances. Staff #11 reported she did not have any grievances just complaints.

Review of the complaint log revealed a complaint written on a plain piece of paper and not on an occurrence form. The complaint stated,

"12645 filing number ___ (Patient #12's name); M# 007226-01 Admitted 1/16/19 Today's date: 1/17/19 ___ (Staff #11's name) Patient advocate spoke with ___ (Patient #12's name) in regards to her commitment paperwork that she had just received and she was very emotional. She stated that she went to MHMR to get help and they tricked her by making her think they were going to help her and then they had officers detain her and bring her to RPBH. She stated she does not need to be here and asked that I speak to Dr. Torres. I spoke to Dr. Torres and he wants to hold her for 72 hours and observe her and see how she is doing. I explained this to ___ (Patient #12) and she was ok and knew she would be released soon if everything goes well."

Staff #11 informed the surveyor that she initially went to see Patient #12 because Patient #12 was upset that she was breast feeding and her baby was at home. Staff #11 reported that she did not write that down because she turned that over to Nursing and was trying to explain to patient #12 about her commitment process. Staff #11 did not have any follow up information concerning the breast feeding issue or what was done. Staff #11 failed to recognize this issue as a grievance. It was not followed through by The Patient Advocate and Grievance Committee nor Quality Assessment Performance Improvement (QAPI).



B.) A tour of the 300-400 unit was conducted on 1/30/19 in the afternoon. Patient #34 was found walking out of the unit with a group of patients. The patients were on their way to group therapy. Patient #34 was found loudly asking to fill out a complaint on one of the staff members. Patient #34 asked three times and the staff was not responding to her request or trying to address the situation. The Mental Health Technician (MHT) continued to keep walking and opening the doors to lead the group out. Staff #13 was asked by the surveyor why Patient #34 was not allowed to make a complaint nor was she even acknowledged. Staff #13 told the nurse to hand her a complaint form. The patient began to walk off and the surveyor asked her if she had a pen or pencil. Patient #34 stated, "no" and handed the complaint form back to the nurse and stated, "I can't do this or I will miss group and left the form on the desk. No staff member reached out to assist the patient in making her complaint or addressed with her after group session was over. The nurse at the desk stated, "she does this all the time." The surveyor asked the nurse, "does this mean she cannot lodge a complaint?" The nurse stated, "she can but it's always the same." The facility staff failed to recognize the patients' rights and failed to assist her in making a formal complaint or grievance.

Based on observation, review of records, and interview, the facility failed to:

A. identify that bathroom doors installed in all patient rooms posed a ligature risk at the hinge pinch point or potential self-harm risk due to removable magnets.

The deficient practices identified above were determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

B. ensure adequate monitoring of patients in the admissions waiting room while unsecured, live electrical outlets were accessible to psychiatric patients seeking admission.

C. 1.) have an effective process for authorized contract staff to enter and exit the facility.
2.) protect vulnerable patients from potential life threatening situations from unidentified individuals, entering the
facility, with free access to all patients in 3 (Unit 200, Unit 300-400, Unit 500-600) out of 3 patient care
areas.

D.) ensure Nursing documented or obtained a physician's order to decrease the level of observation for suicide precautions in 1(33) of 4 (7,31,33 and 35) charts reviewed.. Failure to identify the correct suicide precautions and clear communication for monitoring a suicidal patient could lead to potential patient harm. Staff failed to use safe techniques for patient holds and transfers. Risk Management failed to implement a plan to ensure staff was following safe techniques. Failure to use proper techniques could cause harm and potential injury to a patient in a mental health crisis in 3 (7,35, and 31) of 4 (7,31,33 and 35) charts reviewed.

Nursing failed to assess and reassess patient's after a physical hold or restraint, administration of a chemical restraint, a fall with injury after the administration of a chemical restraint, monitor an injured patient in seclusion, assess the patient before discontinuation of seclusion and failed to assess/monitor the patient after release from seclusion in 3 (7,31, and 35) of 4 (7,31,33, and 35) patient charts reviewed.



Findings included:

A. A tour of the hospital was conducted on 1-28-2019 with Staff #2, Staff #8, and Staff #4 present. While in patient room #505, the bathroom door was observed to have a gap between the narrow portion of the top of the door and the door frame. This gap was not protected by the metal stop that had been installed to reduce the risk of such gaps being used as pinch points. A bed sheet was provided by the facility. The surveyor was able to tie a knot on one end of the sheet, slip the knot into the narrow pinch point, and secure a ligature that would support the weight of a patient. Staff #2 was also able to place sufficient force on the sheet to show that the sheet would support a patient's body weight.

Interview was conducted with Staff #8. Staff #8 stated that all of the bathroom doors were installed in the same manner except one door on the Geriatric unit. Staff #8 advised that it was a prototype door that was being trialed as a possible replacement for all of the bathroom doors in patient rooms throughout the facility. The replacement door on the Geriatric unit (Unit 200) was found to have small round magnets sewn into the edges so that the door could be easily mounted to the door frame, but would not support enough weight to be a ligature risk. However, a potential existed for the magnets to be removed from the edges and created a hazard for a psychiatric patient to swallow in an attempt to harm his/herself.

While examining the prototype door on the Geriatric unit, Patient #33 asked to speak to surveyors. Patient #33 stated that he was suicidal, and the bathroom door in his room was dangerous. Patient #33 described how he would be able to hang himself on the bathroom door in his room using the top of the door as a pinch point. Patient #33 was not present on Unit 500 when the discovery was made. Patient #33 was not in the presence of Staff #8 and surveyors when looking at the prototype door on Unit 200 and was unaware of the findings on Unit 500. Patient #33 had merely been sitting in the day room and observed people inside of a patient room, looking at the prototype door when he asked to speak to surveyors.


B. A patient waiting area for patients seeking admission to the facility was observed during a tour of the facility on 1-28-2019 with Staff #4, Staff #8, and Staff #33. The waiting area was in a restricted access area where patients and potential patients have to be escorted through locked doors. The room was observed to have three electrical outlets in it. These outlets did not have secured covers over them to prevent a potentially suicidal patient from inserting an object into a live circuit in a possible suicide attempt.

Staff #8 was asked if patients were allowed to remain in the room without staff present. Staff #8 confirmed that the patients were allowed to remain in the room without staff present. Staff #8 reported that staff monitored patients via camera in the office across the hall during those times. Staff #8 stated that the circuits to the electrical outlets had been disabled. Upon further investigation, the circuit to the electrical outlet was found to be working and supplying electricity to the outlet.

A tour of the admission office containing the remote monitoring screen was made. It was observed that the camera was angled in such a manner that two of the three live electrical outlets could not be observed by staff when remotely monitoring patients. Staff #33 stated that the facility was aware that the entire room was not observable and that new cameras with wider angles were being explored. Staff #8 and Staff #33 were not able to provide information on when the cameras would be purchased and installed.



32143


C. A tour was conducted in the facility on the morning of 1-28-19. A radiology technician, Staff #36, was observed opening a locked door with a badge and was leaving the patient care area. The technician was pushing a portable x-ray machine. The x-ray machine was heavily soiled, scuffed, and was missing paint.

An interview was conducted with Staff #36 on 1-28-19. Staff #36 was asked who she was and what organization she worked for. Staff #36 gave her name and reported that she was a contracted employee and gave the company's name. Staff #36 reported that she was new in the position and this was her first time here. The surveyor looked at Staff #36's badge and realized it was not Staff #36's name or her picture on the badge. The badge had another name and said therapist under the name. Staff #36 stated that "the therapist up front gave me her ID badge so I could come in and out." Staff #36 reported that she had not had any special training from the facility in how to handle the patients in a crisis situation or a patient incident if it occurred. Staff #36 stated, "I think I'll get training next week."

During an interview with Staff #1 and #8 on 1-28-19 revealed Staff #1 and #8 was not aware contract staff were not given their own badges. Staff #1 and #8 confirmed that the badge was not a contract badge nor Staff #36's. Staff #1 stated, "This is not supposed to happen. We have a process in place and clearly it has not been followed."


D. The following patient situations are related to obtaining orders for precautions, utilizing safe techniques for physical holds and transfers, and properly assessing reassessing patients following restraint or seclusion.

Patient #33

A tour was conducted of unit 200 in the afternoon of 1/28/19. Patient #33 stated to the surveyors, "I can tell you how to kill yourself in that room." Patient #33 was asked how he could kill himself. Patient #33 stated, "I would just tie a knot in a sheet and hang it over the bathroom door. I thought about it last night." Patient #33 reported that he was suicidal last night. Patient #33 confirmed he was still having thoughts of suicide with a plan.

Review of patient #33's chart revealed he was a 61-year-old male admitted to the facility on 1/25/19 with a diagnosis of suicidal ideation and psychosis. The physician orders dated 1/25/19 at 1:40AM revealed the Patient #33 was placed on Unit restriction, Seizure and Suicidal Precautions. The order stated the patient would be on every 15-minute observation.

Review of Patient #33's nurse's notes dated 1/25/19 at 0300 (3:00AM) revealed Patent #33 was on "unit restriction due to SI with plan." The nurse documented on the Columbia-Suicidal Severity rating form that the patient was having thoughts of killing himself and had a plan. He was put at a "moderate risk" level.

"A moderate suicide risk level includes 15 minute checks or close observation as specified by the physician.
Reassessment with the suicide risk assessment monitoring once every shift during hospitalization.
Documentation per shift in the progress notes related to the status of the patients.
The physician will conduct daily reevaluation related to the appropriateness of the level of care and placement.
The RN will discuss findings from the tool with the multidisciplinary team during treatment team reviews, and at a minimum with the physician, and therapist daily, in order to verify the most appropriate level of observation for safety.
Potential for Self-Harm Treatment Plan initiated and /or updated.
Ensure an orange arm band is placed on patient and ensure a corresponding MD order is obtained."

Review of patient #33's chart revealed there was two more suicidal screening tool performed on 1-25-19. The second one was at 1600 (4:00PM) which stated the patient denied all suicidal thoughts or actions. The nurse failed to complete the screening form by marking if the patient was a Low Risk, Moderate Risk, or High Risk for suicidal ideation.

Review of the physician orders dated 1/25/19 at 12:01PM revealed a telephone order to "DC UR" (discontinue unit restriction). There was no order to remove Patient #33 from suicide precautions or change the level of monitoring (moderate with every 15-minute observation).

Review of the Nurses Notes dated 1/26/29 revealed there was two more suicidal screening tool performed on 1-26-19 at 10:00AM and 8:00PM. Both screenings were marked no for suicidal thoughts or plans. The forms were checked low risk. There was no documentation that the physician was notified and no nursing documentation that Patient #33 had been removed from suicide precautions or lowered to a low risk.

Review of the physician orders dated 1/26/19 at 1313 (1:13PM) revealed a telephone order that stated, "Pt may have his cap." There was no order to change the patient's status or monitoring for suicidal thoughts and behaviors.

Review of the Physician Progress notes dated 1/26/19 at 1713 (5:13PM) revealed no documentation of the patient's suicidal precautions or if the patient was still suicidal.

Review of the nurse's notes dated 1/27/19 (no time documented) stated, "___ (Patient #33) expressed desire to use a string to strangle himself. A piece of string was removed from pts possession on 1/26/19. He also wrote on 'Core' that he wanted to die. He has been raised to a Moderate Suicide Risk due to his statements. Dr. ___ (psychiatrist) informed. There was no nursing or physician documentation that Patient #33's suicide precautions were ever discontinued or lowered from a moderate risk.

Review of the physician orders dated 1/27/19 at 1150 (11:50AM) stated, "Increase suicide level risk to moderate, due to statements made by the patient." There was no order found to take the patient off of the moderate suicide precaution from the admission.

Patient #7

Review of Patient #7's chart revealed he was a 20-year-old male admitted on 1/5/19. Review of the physician orders revealed a telephone order "Physician Orders for Restrictive Interventions" dated 1/6/19 at 1311 (1:13PM). The orders revealed Patient #7 to be placed in seclusion, physical restraint, and emergency behavioral medications (EBM). Patient #7 was ordered Haldol (antipsychotic) 10mg x 1 IM, Ativan (sedative) 2mg x1 IM, and Benadryl (Antihistamine) 50mg x 1 IM. "reason for intervention is danger to others, threatening staff and peers and punching walls." In the nurse's section of the form it stated, "I authorize ___ (Staff #12's first name only) RN to complete 1- Hour Face to Face Assessment.

Review of the physician's section of the order asked the physician to fill out the following information:

"Lesser Restrictive interventions implemented by physician that were not successful: (check all that apply):
Change in environment, Time Away, De-escalation, Active listening /1:1 with patient, Problem solving, removed from stimuli, Physical activity and reason lesser interventions were rejected:
Lack of patient response/condition, Other
Physician ordering RI communicated with Attending Physician.
Attending Physician concurred with intervention yes or no?
Complications with Restrictive Intervention? Yes, or No. If Yes, explain:
Physician signature/ Date and Time."

The physician had signed the physician section on 1/6/19 at 1400 (2:00PM). The physician had left all of the above information blank. There was no documentation that the physician did the 1-hour face to face or assessed the patient when he signed the order at 1400 (2:00PM); 44 minutes after the telephone order was given.

Review of the "Restrictive Intervention Reporting Form" dated 1-6-19 at 1311 (1:13PM). The form stated Patient #7 "de-escalation: tried talking to the patient and Problem solving: tried to find out what's upsetting him-no change."

On 1/29/19 in the afternoon, the unit 300 video, was observed by the surveyors and Staff #37. There was no sound on the videos. Review of the Video of 1/6/19 showed the following:

1:10:05PM- The male MHT had Patient #7 in a hold and took him to the ground. Patient #7 was fighting and talking during the hold.

1:10:15- Three more MHT come to assist and hold the patient's feet and legs. Two nurses came out into the hallway, Staff #29 and Staff #12. Each nurse was wearing gloves. Both nurses were holding hyper dermic needles. Staff #29 gave an injection in the right arm and staff #12 gave an injection in the left arm. Only Staff #29 documented that she gave an injection.

1:15:15PM- Patient #7 is dragged backwards into the seclusion room by the male MHT. Review of the policy and procedure "Seclusion and Physical or Chemical Restraint" stated,

1:17:00- Patient #7 is taken to the ground and is held on the floor inside the seclusion room by two male MHT's and one female. Review of the facility's policy and procedure "Seclusion and Physical or Chemical Restraint" stated, "The implementation of the order for restraint and seclusion will only be carried out under the direct supervision of an RN, who is competent for this procedure. There was only one RN, Staff #29, who signed all the notes concerning the "Restrictive Intervention Observation/Assessment Flow Sheet."

Review of the video showed Patient #7 taken into the seclusion room and Staff #29 was not present. Patient #7's hand was lacerated while the MHT was trying to close the door to the seclusion room and Staff #29 was not present. Patient #7 is taken to the ground and is held on the floor inside the seclusion room by two male MHT's and one female and Staff #29 was not present. Review of the facility's policy and procedure "Seclusion and Physical or Chemical Restraint" stated, "Restraints and Seclusions cannot be used Simultaneously."

1:18:06- Staff #29 came out of the nurse's station and looked into the seclusion room while Patient #7 was being held on the ground in the seclusion room. Staff #29 walked away and back through a closed door to the nurse's station at 1:18:13PM. Staff #29 only observed the injured patient visually for 7 seconds.

1:22:16PM- Staff #29 returns to the seclusion room with gloves on and gauze in her hand. Staff #29 looks down at the ground at Patient #7 and the door closes with no further video.

1:22:49- Staff #29 and four MHT's exit the seclusion room and the Staff #29 goes back into the nurse's station.

1:32:38- Patient #7 was given a cup by the MHT. The MHT set the cup on the floor and the patient was seen sitting on the floor.

1:38:56- Patient #7 was picked up under the arms by two MHT's and taken from the seclusion room. Patient #7 was having difficulty walking and was being carried under his arms down the hallway to his room. Staff # 29 was not observed (by video) assessing the patient for release from seclusion. Staff #29 documented that she had assessed the patient for, physical status and comfort, psychological status and comfort, circulation/ROM, and to determine need to continue restraint /seclusion or try less restrictive interventions at 1311,1317,1320,1321,1326,1331,1336, and 1340. Staff #29 nor any other staff were visually observed taking a blood pressure cuff into the seclusion room to take Patient #7's vital signs. Staff #29 documented that Patient #7 had refused.

3:12:30PM- A MHT entered Patient #7's room with a blood pressure machine. The MHT exited the room at 3:12:42 a total of 12 seconds.

Review of Patient #7's Face to Face documentation revealed Staff #12 documented that she had performed the face to face. Review of the physician order to administer the chemical restraint on 1/6/19 revealed Staff #12 was designated as the nurse to administer the face to face. However, Staff #12 was involved in initiating the chemical restraint according to the video observed.

Review of the facility's policy and procedure "Seclusion and Physical or Chemical Restraint" stated, "3. Once a physical/chemical restraint or seclusion has been implemented the qualified RN shall conduct a face-to-face assessment using the Seclusion/Restraint Hourly Flow Sheet. Assessment will include evaluation of patient's immediate situation; reaction to the intervention; current psychological status and need to continue or terminate the emergency intervention; physical assessment including skin integrity, respiratory/circulatory status, nutrition/hydration, pain, and review of medications; and lab results."

Review of Patient #7's chart revealed Staff #12 performed the face to face on 1/6/19 at 1345 (1:45PM). Review of the video revealed Staff #12 did not go into Patient #7's room until 2:11:28PM and was out of the room at 2:11:43PM; a total of 20 seconds. Staff #12 did not have any equipment with her to check the patient's vital signs. Staff #12 documented, "Pt appears to be sleeping. Resting quietly with eyes closed. Respirations even and unlabored. Color within normal limits."

An interview was conducted with Staff #12 and #29 on the afternoon of 1/29/19. Staff #12 was asked if she remembered the restraint in the afternoon of 1/6/19 with Patient #7. Staff #12 had the patients chart and stated that she did remember. Staff #12 was asked what was involved in performing a face to face. Staff #12 stated, "you go down to the patient's room and do a head to toe assessment. You know you get their vital signs and then check on them like every 15 minutes." Staff #12 was asked if she did a head to toe assessment and took Patient #7's vital signs. Staff #12 stated that she had done the assessment and took vital signs. There were no vital signs documented on Patient #7.

Staff #29 was asked if she remembered what happened with Patient #7 in the afternoon of 1/6/19. Staff #29 had Patient #7's chart and stated, "yes, I do."

Staff #29 had documented patient #7 refused vital signs at 30 minutes' post medication, one-hour post medication, 2 hours post medication, and temperature 1-2 hours post medication." Staff #29 documented, at one hour and at two hours: I have reviewed all elements of the patient's assessment from the information provided including the patient's physical and psychological status, VS, any patient care requirements, patient response to the chemical restraint, and continued need for intervention."

Staff #29 was asked if she had gone down to assess Patient #7 at each vital sign time and assessed the patient. Staff #29 stated, "Yes, I went down there three or four times to check on him but he would not let me take his vital signs. Review of the video from 1/6/19 from 1300-1500 (1:00PM-3:00PM) revealed Staff #29 never went down the hallway and into Patient #7's room to assess the patient or to even visually view the patient.

On 1/29/19 in the afternoon an interview was conducted with Staff #39 concerning the video and observations made. Staff #39 confirmed the above findings and stated that he did not see Staff #29 go into Patient #7's room and assess the patient. Staff #39 reported that he saw Staff #12 go in and come out of Patient #7's room in 20 seconds with no vital sign equipment. Staff #39 confirmed this was not appropriate care and the staff did not follow policy and procedures of the facility.


Patient #35

Review of Patient #35's chart revealed she was a 30-year-old admitted to the facility on 1/16/19 with a diagnosis of schizophrenia and other psychotic disorders. Patient #35 was involuntary and placed on elopement precautions and every 15 minute observations.

Review of the physician orders revealed a telephone order for "Haldol 5 mg, Ativan 2 mg and Benadryl 50mg IM now for agitation and anxiety." Review of the Medication Administration Record (MAR) revealed the Emergency Behavioral Medications were administered at 2215 (10:15PM).

Review of the nurse's notes dated 2215 (10:15PM) stated, "Patient is extremely agitated, attempting to get out doors, and running in hallway into walls. Patient refused to be redirected. Patient was given emergency meds per Dr. ___ (psychiatrist) IM. Patient was physically restrained and shots given. Patient was then released and went to her room. 2240 Patient was physically restrained twice more due to continued agitation, attempting to run into walls and through doors. Patient eventually went to her room and lay on the floor after being coerced to come out of the bathroom. Will monitor LOS during shift."

Review of the physician order for restrictive intervention revealed the physician section was signed by the physician but was left blank. The nurse failed to document at "one hour and at two hours: I have reviewed all elements of the patient's assessment from the information provided including the patient's physical and psychological status, VS, any patient care requirements, patient response to the chemical restraint, and continued need for intervention."

On 1/30/19 in the afternoon the 300-unit video was viewed for 1/16/19 in the evening hours. Staff #1, 13,3, and 38 viewed the video of Patient #35 on 1/16/19 at 10:13PM.

Review of the video dated 1/16/19 at 10:13:09PM revealed Patient #35 was running down the hallway and was trying to go into a room. The MHT grabbed the patient and pulled on the patient's arm that could cause injury and was not part of the "handle with care" training. Patient #35 was taken to the ground and given an EBM. At 10:32:27 patient #35 was seen lying on the floor in front of the nurse's station. At 10:37:07 Patient #35 jumps up off the floor and attempts to run. The MHT sticks his arm out and catches the patient in her throat. Patient #35 was brought down to the floor. Staff # 38 confirmed that the holds and actions taken to stop the patient was not the appropriate part of the training for physical holds. Staff #35 stated that he was planning on retraining after viewing the videos.


Patient #31

Review of Patient #31's chart revealed he was a 71-year-old male admitted to the facility on 1/23/19. He was involuntary and placed on fall, suicide, and unit restriction precautions. Patient #31 was put on every 15-minute observation.

Review of the physician ordered written on 1/23/19 at 1819 (6:19PM) revealed Patient #31 had a telephone order written for "Haldol, 5 mg IM now, Benadryl 50 mg IM now and Ativan 2 mg IM now." There was no reason on the order for the medication. The telephone order was not signed by the physician as of 1/29/19.

Review of the unit video for 1/23/19 at 6:30PM revealed Patient #31 siting at the dining table talking to patients.
Patient #31 was animated with his hands but was not acting in a threatening manner. At 6:33PM the RN and MHT came to the table and was talking to Patient #31. The staff was standing over the patient. Patient #31 was looking up to the nurse, pointing and talking. The patient appeared agitated at this point. At 6:43PM the nurse returned to the nurse's station and the MHT walked away. Patient #31 continued to talk to the other patients sitting at the table. The RN was seen talking on the hand held walkie talkie at 6:44:50. At 6:59:53 three other male MHT's showed up on the unit and walked towards Patient #31. At 7:03 the staff removed the other patients from the dining area. Patient #31 became more agitated at 7:10PM and stood up and walked around the unit. At 7:11;27 the patient was grabbed by both arms by two male techs and pushed against the wall in a rough manner. A third MHT pulled the Patient #31's feet out from under him and he landed on his buttocks on a hard tile floor. At 7:11;57 the nurse administered an injection in the patients rt arm. At 7:12:35 Patient #31 was released from the hold and was not assisted off the floor. All of the staff walked away. The patient was left by the staff to get up off the floor by himself. The patient went back to the dining table and sat down by himself. TheMHT, not the RN, attempted to get vital signs on Patient #31. At 7:45 the MHT attempted to get Patient #31 to sit in a wheel chair. At 7:50Pm Patient #31 in the wheel chair and was escorted to his room by the nurse and MHT. There was no vital sign equipment taken into the patient's room. There was no further nursing assessment documented until 1/23/19 at 2245 (10:45PM).

Review of the Nurses notes dated 1/23/19 at 2245 (10:45PM) stated, "MHT found pt on the floor, notified RN. RN assessed pt vs 141/77, 97.8, 67, 98.9, 18. Pt very sleepy-not able to make a clear statement-bump on the center of the pts head. RN notified the house supervisor. 2300 (11:00PM) MHT, house supervisor helped/assisted pt to a wheelchair-room change made.pt very sleepy. 2305 (11:05PM) RN notified on call primary care____ (providers name)- orders received to do neuro checks on pt and to monitor pt. 2325- pt moved closer to a room beside nursing station- pt on fall precautions q 15 minute checks." There was no nursing documentation that a head to toe assessment was performed on the patient to assess for injuries due to fall or the physical hold and take down to administer EBM's.

An interview was conducted with Staff #3 and #13 in the afternoon of 1/30/19. Staff #3 stated that the Risk committee had been viewing the videos after restraints were applied to see if they were performed correctly and have found some issues but were not aware of the issues found by the surveyor. Staff #13 and #3 confirmed they had not been watching the whole video to see if the patients were being monitored appropriately. Staff #3 stated that there were issues noted with some of the holds and restraints reviewed but Risk committee and Quality Assessment Performance Improvement (QAPI). The facility had not attempted to address the findings and put a process in place to prevent patient injuries.

Based on review of records, observation, and interviews, the facility failed to:


A.) prevent neglect by providing the patients with clean clothes. Provide needed clothes to promote patient dignity and avoid mental anguish in the milieu in 1(33) of 3 (#31,#32, and #33) patient observations on the 200 Geri/psych unit.


B.) provide a place for patients to sit down or lie down while being secluded. Patients were forced to sit or lie down on the floor in 3 (Unit 200, 300-400, and 500-600) out of 3 seclusion rooms.


Findings included:

A.) A tour was conducted of unit 200 (Geri/psych) on the afternoon of 1/28/19. Patient #31 was found sitting in the dining area eating his lunch. Patient #31 was wearing paper scrubs. He also had a pull over jacket on. On 1/29/19 Patient #31 was still in paper scrubs and was found outside in 40-degree weather smoking with no jacket or warm clothing. On 1/30/19 Patient #31 was in paper scrubs and socks.

An interview was conducted on 1/30/19 at 2:04PM with Staff #35. Staff #35 was asked why Patient #31 was in paper scrubs and has any effort been made to contact family or friends to help get his clothes. Staff #35 stated, "He's wearing paper scrubs because he was suicidal. We take all their clothes away if they are suicidal. It's to keep them from hanging themselves with their clothes." Patient #31 was standing in front of Staff #35 wearing his pull over shirt/jacket as she was explaining to the surveyor why he could have no personal clothes. Staff #35 reported it was the policy not to let suicidal patients have their own clothing. Staff #35 was asked about the patient's underwear and if he had clean underwear. Staff #35 stated, "We have that fish net underwear he can wear. You know, like we give to the ladies when they are on their periods and need to wear a Kotex." Staff #35 was unable to tell the surveyor what policy and procedure she was referring to, if the patient had on clean underwear or not, if family or friends had been notified to bring clothes, or if the facility had made arrangements to get the patient clothes appropriate for the facility and weather.

An interview with Staff #13 on the afternoon of 1/30/19 revealed he was unaware of a policy that stated a patient was not to have their clothing if suicidal, only unsafe clothing with strings or ties. Staff #13 confirmed that Patient #35 had jeans and underwear when he came in and will retrieve the cleaned items for the patient.


B.) Review of the Seclusion Rooms on Unit 200, 300-400, and 500-600 revealed they were empty. The three seclusion rooms had dirty and soiled tile floors. There was no place for a patient to sit or lie down while in seclusion. A video was reviewed of Patient #7 on unit 300-400. The video was dated and time stamped at 1/6/19 at 1:15:13PM. The video revealed Patient #7 was given an Emergency Behavioral Medication (EBM) on the unit hallway and was escorted to the designated "Seclusion" room. Patient #7 was taken to the ground in the seclusion room and staff were holding the patient down on the dirty and soiled floor.
An interview with staff #13 on afternoon of 1/30/19 stated that there was no furniture in the room but they could pull a mattress in the room if needed. Staff #13 reported that the patients are not given pillows or sheets for safety reasons. Staff #13 was asked what mattresses would be placed in the room and he stated, "we would find one somewhere." Staff #13 was asked if patients had ever been given a mattress in seclusion and staff #13 reported he was not aware of a time when they had.

Based on review, observation and interview the facility failed to:

1.) Follow physician orders for the administration of medications and failed to notify physician in 1(12) of 4 (7,12,31, and 35) patient charts reviewed.

2.) To have any physician, nursing assessment, or interventions concerning Patient #12's pain, discomfort, or inflammation of breast, and failed to assess and reassess after vomiting. The facility failed to supply the patient with medical equipment needed to assist with breast pumping. There was no further documentation that the patients baby was followed up on or if the baby was safe and able to get nutrition. Nursing had no further documentation of the patient's breast or if the patient was having any complications in 1(#12) of 1 patient charts reviewed of nursing mothers.

3.) Nursing failed to assess and reassess patients after a physical hold or restraint, administration of a chemical restraint, a fall with injury after the administration of a chemical restraint, monitor an injured patient in seclusion, assess the patient before discontinuation of seclusion and failed to assess/monitor the patient after release from seclusion in 3 (7,31, and 35) of 4 (7,12,31, and 35) patient charts reviewed.



Patient #12

Review of Patient 12's chart revealed she was a 22-year-old female admitted to the facility on 1/16/19 with a diagnosis of Suicidal Ideation. Patient #12 was brought to the facility under a peace officers warrant and was very upset and agitated.

Review of the physician orders on 1/16/19 at 1733 (5:33PM) revealed a telephone order, "Haldol 5mg IM x1, Ativan 2 mg IM x1, and Benadryl 50mg IM x 1." A second physician order was found on 1/16/19 at 1800 (6:00PM). The order stated, "Above order for dangerous, agitated, no redirectable behavior, less intrusive measures not available." (sic)

Review of the Nurses notes dated 1/16/19 at 2208 (10:08PM) stated, "Previous shift irate patient had order for IM emergency medication. Educated patient about it but she refused the (illegible word) was given Benadryl 50mg po QHS prn insomnia with good effect." Review of the physician orders revealed there was no orders to discontinue the emergency behavioral medication. There was no documentation of the medications administered nor any documentation the physician was notified. The nurse failed to follow physician orders.

Review of Patient #12's chart revealed a physician's psychiatric exam dated 1/17/19 and the discharge summary dated 1/19/19 at 12:00PM. In both summaries the physician dictated that the patient was currently breast feeding her baby.

Review of the Interdisciplinary Treatment Plan revealed a statement dated 1/17/19, "Pt refused to not start meds due to breastfeeding." There were no other interventions concerning her inability to breast feed her child.
Review of the physician orders dated 1/17/19 at 1630 (4:30PM) revealed a telephone order, "May use pump for breast pumping if she supplies it."

Review of the history and physical dated 1/17/19 (no time documented) revealed the patient refused to have a physical and requested a physical by her own physician. The physician did not document any information concerning her breast except "no complaints." There was no physician documentation that the patient was asked about her breast feeding and if she had any pain, discomfort, or inflammation.

Review of the Nurses Notes dated 1/17/19 at 1200PM stated, "AX0X4. Denies SI-HI no AVH. Pt is depressed, anxious and very irritable. Need redirection frequently. Barely understand nurse request. Denies physical distress. D/C unit restriction for suicide precautions @1534. (illegible word x2) may use pump for breast pumping if she supplies it. Pt worries about her baby." There was no found documentation that the patient was assisted in obtaining a breast pump or if she even had one. The facility failed to supply the patient with medical equipment needed to assist with pumping. There was no further documentation that the patients baby was followed up on. If the baby was safe and able to get nutrition. Nursing had no further documentation of the patient's breast or if the patient was having any complications.

Review of the Mental Health Technicians (MHT) notes dated 1/17/19 stated, "Pt over reacted most of shift. Pt. cried, yelled for a time, until was redirected to tone and calm down. Pt threw up at 22:02. Pt slept most of the night." There was no documentation in the nursing notes that the patient was given positive reinforcement or de-escalation techniques for redirection. There was no documentation that the patient had vomited or any assessment after the patient vomited.


Patient #7

Review of Patient #7's chart revealed he was a 20-year-old male admitted on 1/5/19. Review of the physician orders revealed a telephone order "Physician Orders for Restrictive Interventions" dated 1/6/19 at 1311 (1:13PM). The orders revealed Patient #7 to be placed in seclusion, physical restraint, and emergency behavioral medications (EBM). Patient #2 was ordered Haldol (antipsychotic) 10mg x 1 IM, Ativan (sedative) 2mg x1 IM, and Benadryl (Antihistamine) 50mg x 1 IM. "reason for intervention is danger to others, threatening staff and peers and punching walls." In the nurse's section of the form it stated, "I authorize ___ (Staff #12's first name only) RN to complete 1- Hour Face to face Assessment.

Review of the "Restrictive Intervention Reporting Form" dated 1-6-19 at 1311 (1:13PM). The form stated Patient #7 "de-escalation: tried talking to the patient and Problem solving: tried to find out what's upsetting him-no change."
On 1/29/19 in the afternoon, the unit 300 video, was observed by the surveyor's and Staff #37. There was no sound on the videos. Review of the Video on 1/6/19 showed the following:

1:10:05PM- The male MHT had Patient #7 in a hold and took him to the ground. Patient #7 was fighting and talking during the hold.

1:10:15- Three more MHT's come to assist and hold the patient's feet and legs. Two nurses came out into the hallway, Staff #29 and Staff #12. Each nurse was wearing gloves. Both nurses were holding hyper dermic needles. Staff #29 gave an injection in the right arm and staff #12 gave an injection in the left arm. Only Staff #29 documented that she gave an injection.

1:15:15PM- Patient #7 is dragged backwards into the seclusion room by the male MHT.

1:17:00- Patient #7 is taken to the ground and is held on the floor inside the seclusion room by two male MHT's and one female. Review of the facility's policy and procedure "Seclusion and Physical or Chemical Restraint" stated, "The implementation of the order for restraint and seclusion will only be carried out under the direct supervision of an RN, who is competent for this procedure. There was only one RN, Staff #29, who signed all the notes concerning the "Restrictive Intervention Observation/Assessment Flow Sheet."

Review of the video showed Patient #7 taken into the seclusion room and Staff #29 was not present. Patient #7's hand was lacerated while the MHT was trying to close the door to the seclusion room and Staff #29 was not present. Patient #7 is taken to the ground and is held on the floor inside the seclusion room by two male MHT's and one female and Staff #29 was not present. Review of the facility's policy and procedure "Seclusion and Physical or Chemical Restraint" stated, "Restraints and Seclusions cannot be used Simultaneously."

1:18:06- Staff #29 came out of the nurse's station and looked into the seclusion room while Patient #7 was being held on the ground in the seclusion room. Staff #29 walked away and back through a closed door to the nurse's station at 1:18:13PM. Staff #29 only observed the injured patient visually for 7 seconds.

1:22:16PM- Staff #29 returns to the seclusion room with gloves on and gauze in her hand. Staff #29 looks down at the ground at Patient #7 and the door closes with no further video. Staff #29 documented, "at 1320 when pt tried to get out of the S room he got his L hand caught in the door and had two small cuts; 1 cut on his second finger and 1 cut on his third finger. 1326- nurse attempted to assess his wound and to clean and dress it but pt. refused. 1845 Pts hand cleansed and band aids applied." There was no documentation that the physician was notified of Patient #7's injuries in the seclusion room or physician orders to treat the wounds.

1:22:49- Staff #29 and four MHT's exit the seclusion room and Staff #29 goes back into the nurse's station.

1:32:38- Patient #7 was given a cup by the MHT. The MHT set the cup on the floor and the patient was seen sitting on the floor.

1:38:56- Patient #7 was picked up under the arms by two MHT's and taken from the seclusion room. Patient #7 was having difficulty walking and was being carried under his arms down the hallway to his room. Staff # 29 was not observed (by video) assessing the patient for release from seclusion. Staff #29 documented that she had assessed the patient for, physical status and comfort, psychological status and comfort, circulation/ROM, and to determine need to continue restraint /seclusion or try less restrictive interventions at 1311,1317,1320,1321,1326,1331,1336, and 1340. Staff #29 nor any other staff were visually observed taking a blood pressure cuff into the seclusion room to take Patient #7's vital signs. Staff #29 documented that Patient #7 had refused.

3:12:30PM- A MHT entered Patient #7's room with a blood pressure machine. The MHT exited the room at 3:12:42 a total of 12 seconds.

Review of the facility's policy and procedure "Seclusion and Physical or Chemical Restraint" stated, "3. Once a physical/chemical restraint or seclusion has been implemented the qualified RN shall conduct a face-to-face assessment using the Seclusion/Restraint Hourly Flow Sheet. Assessment will include evaluation of patient's immediate situation; reaction to the intervention; current psychological status and need to continue or terminate the emergency intervention; physical assessment including skin integrity, respiratory/circulatory status, nutrition/hydration, pain, and review of medications; and lab results."

Review of Patient #7's chart revealed Staff #12 performed the face to face on 1/6/19 at 1345 (1:45PM). Review of the video revealed Staff #12 did not go into Patient #7's room until 2:11:28PM and was out of the room at 2:11:43PM; a total of 20 seconds. Staff #12 did not have any equipment with her to check the patient's vital signs. Staff #12 documented, "Pt appears to be sleeping. Resting quietly with eyes closed. Respirations even and unlabored. Color within normal limits."

An interview was conducted with Staff #12 and #29 on the afternoon of 1/29/19. Staff #12 was asked if she remembered the restraint in the afternoon of 1/6/19 with Patient #7. Staff #12 had the patients chart and stated that she did remember. Staff #12 was asked what was involved in performing a face to face. Staff #12 stated, "you go down to the patient's room and do a head to toe assessment. You know you get their vital signs and then check on them like every 15 minutes." Staff #12 was asked if she did a head to toe assessment and took Patient #7's vital signs. Staff #12 stated that she had done the assessment and took vital signs. There were no vital signs documented on Patient #7.

Staff #29 was asked if she remembered what happened with Patient #7 in the afternoon of 1/6/19. Staff #29 had Patient #7's chart and stated, "yes, I do."

Staff #29 had documented patient #7 refused vital signs at 30 minutes' post medication, one-hour post medication, 2 hours post medication, and temperature 1-2 hours post medication." Staff #29 documented, at one hour and at two hours: I have reviewed all elements of the patient's assessment from the information provided including the patient's physical and psychological status, VS, any patient care requirements, patient response to the chemical restraint, and continued need for intervention."

Staff #29 was asked if she had gone down to assess Patient #7 at each vital sign time and assess the patient. Staff #29 stated, "Yes, I went down there three or four times to check on him but he would not let me take his vital signs. Review of the video from 1/6/19 from 1300-1500 (1:00PM-3:00PM) revealed Staff #29 never went down the hallway and into Patient #7's room to assess the patient or to even visually view the patient.

On 1/29/19 in the afternoon an interview was conducted with Staff #39 concerning the video and observations made. Staff #39 confirmed the above findings and stated that he did not see Staff #29 go into Patient #7's room and assess the patient. Staff #39 reported that he saw Staff #12 go in and come out of Patient #7's room in 20 seconds with no vital sign equipment. Staff #39 confirmed this was not appropriate care and the staff did not follow policy and procedures of the facility.


Patient #35

Review of Patient #35's chart revealed she was a 30-year-old admitted to the facility on 1/16/19 with a diagnosis of schizophrenia and other psychotic disorders. Patient #35 was involuntary and placed on elopement precautions and every 15 minute observations.

Review of the physician orders revealed a telephone order for "Haldol 5 mg, Ativan 2 mg and Benadryl 50mg IM now for agitation and anxiety." Review of the Medication Administration Record (MAR) revealed the Emergency Behavioral Medications were administered at 2215 (10:15PM).

Review of the nurse's notes dated 2215 (10:15PM) stated, "Patient is extremely agitated, attempting to get out doors, and running in hallway into walls. Patient refused to be redirected. Patient was given emergency meds per Dr. ___(psychiatrist) IM. Patient was physically restrained and shots given. Patient was then released and went to her room. 2240 Patient was physically restrained twice more due to continued agitation, attempting to run into walls and through doors. Patient eventually went to her room and lay on the floor after being coerced to come out of the bathroom. Will monitor LOS during shift."

Review of the physician order for restrictive intervention revealed the physician section was signed by the physician but was left blank. The nurse failed to document at "one hour and at two hours: I have reviewed all elements of the patient's assessment from the information provided including the patient's physical and psychological status, VS, any patient care requirements, patient response to the chemical restraint, and continued need for intervention."


Patient #31

Review of Patient #31's chart revealed he was a 71-year-old male admitted to the facility on 1/23/19. He was involuntary and placed on fall, suicide, and unit restriction precautions. Patient #31 was put on every 15-minute observation.

Review of the physician ordered written on 1/23/19 at 1819 (6:19PM) revealed Patient #31 had a telephone order written for "Haldol, 5 mg IM now, Benadryl 50 mg IM now and Ativan 2 mg IM now." There was no reason on the order for the medication. The telephone order was not signed by the physician as of 1/29/19.

Review of the unit video for 1/23/19 at 6:30PM revealed Patient #31 siting at the dining table talking to patients. Patient #31 was animated with his hands but was not acting in a threatening manner. At 6:33PM the RN and MHT came to the table and was talking to Patient #31. The staff was standing over the patient. Patient #31 was looking up to the nurse, pointing and talking. The patient appeared agitated at this point. At 6:43PM the nurse returned to the nurse's station and the MHT walked away. Patient #31 continued to talk to the other patients sitting at the table. The RN was seen talking on the hand held walkie talkie at 6:44:50. At 6:59:53 three other male MHT's showed up on the unit and walked towards Patient #31. At 7:03 the staff removed the other patients from the dining area. Patient #31 became more agitated at 7:10PM and stood up and walked around the unit. At 7:11;27 the patient was grabbed by both arms by two male techs and pushed against the wall in a rough manner. A third MHT pulled the Patient #31's feet out from under him and he landed on his buttocks on a hard tile floor. At 7:11;57 the nurse administered an injection in the patients rt arm. At 7:12:35 Patient #31 was released from the hold and was not assisted off the floor. All of the staff walked away. The patient was left by the staff to get up off the floor by himself. The patient went back to the dining table and sat down by himself. The nurse not the MHT attempted to get vital signs on Patient #31. At 7:45 the MHT attempted to get Patient #31 to sit in a wheel chair. At 7:50Pm Patient #31 at in the wheel chair and was escorted to his room by the nurse and MHT. There was no vital sign equipment taken into the patient's room.

Review of the Nurses notes dated 1/23/19 at 2245 (10:45PM) stated, "MHT found pt on the floor, notified RN. RN assessed pt vs 141/77, 97.8, 67, 98.9, 18. Pt very sleepy-not able to make a clear statement-bump on the center of the pts head. RN notified the house supervisor. 2300 (11:00PM) MHT, house supervisor helped/assisted pt to a wheelchair-room change made.pt very sleepy. 2305 (11:05PM) RN notified on call primary care____ (providers name)- orders received to do neuro checks on pt and to monitor pt. 2325- pt moved closer to a room beside nursing station- pt on fall precautions q 15 minute checks." There was no nursing documentation that a head to toe assessment was performed on the patient to assess for injuries due to fall or the physical hold and take down to administer EBM's.

Based on observation and review of records, nursing staff failed to follow hospital policy for accepting verbal orders in 2 (Patient #21 and Patient #24) of 2 instances of observed verbal orders. Nursing Staff failed to read the orders back to the physician as written to ensure they were written correctly and to decrease the risk of patients being harmed by an incorrect order.

Findings included:

On the morning of 1-30-2018, treatment teams for Patient #21 and Patient #24 were observed. Staff #14 was the physician directing the treatment team remotely through video display on an electronic device. At the end of treatment team, Staff #34 (Registered Nurse) was asked to take verbal orders for each patient for medication. Staff #34 wrote the orders for Patient #21 in the patient's chart as the physician was dictating them. Upon completion of dictation, Staff #34 asked, "Is that all?" Staff #14 indicated that was all for that patient. Staff #34 then wrote the verbal orders for Patient #24 in the patient's chart as Staff #14 was dictating them. Upon completion, Staff #34 again asked, "Is that all?" The physician indicated it was. At no time did Staff #34 read the order back to the physician (Staff #14) to ensure the orders were written correctly. As the treatment team members were moving the electronic device with live video display of Staff #14 to another unit to continue another treatment team, the surveyor stopped them and requested the nurse read back the orders for accuracy. Staff #34 then read the orders back to Staff #14 and verified them.

Review of Policy and Procedure: 1400.3, Subject: Orders, Reviewed / Revised: 06/2017 was made. The review was as follows:

"POLICY
Each patient's care will be directed by Physician's Order. Transcription is implemented by Licensed Nursing Staff or Unit Secretaries. All orders for treatment Shall be in writing. A telephone or verbal order shall be considered to be in writing if dictated to a registered nurse (or the pharmacist) functioning within his/her scope of practice and signed by the responsible physician. Physician telephone orders are to be authenticated as soon as possible with the exception of hazardous order, i.e. S/R. Failure to authenticate Hazardous Orders within 24-hours may be brought to the attention of the Health Information Management Committee, Peer Review Committee and/or any other committee for further discussion and/or appropriate recommendations for action.


PROCEDURE

...

2. Licensed Nursing Staff may accept a telephone order (T.O.) from the physician.

2.1 The RN or LPN (sic) will write the telephone order into the patient's records on the physician's order sheet verbatim as the physician gives the order.

2.2 The RN or LPN (sic) will read back the order to the physician and document that.

2.3 The RN or LPN (sic) will date, time, and note the order as a telephone order (i.e., "T.O.R.B. Dr. Jones/Mary Smith, RN").

2.4 The Licensed Nursing Staff or Unit Secretary will transcribe the order.

2.5 The order is flagged for the physician to sign within 24 hours.

3. A verbal order (V.O.) is utilized when the physician is physically present on the unit and gives an emergency order to the Licensed Nurse. To avoid miscommunication, verbal orders are not to be used routinely."

Based on record review, observation, and interview, the Pharmacy failed to ensure:

A. the unusable medications were managed, all expired or mislabeled medications were removed from the cabinet and not available for patient use;

B. the Pharmacy was labeling medications properly to prevent a medication error; and

C. all medications from discharged patients were disposed of and not readily available for patient use in 1 (unit 300-400) of 3 (unit 300-400, 500-600, 200) medication cabinets.


Unit 300-400 Nurses Station and Medication Room

A tour was conducted of the 300-400 unit nurses station in the morning hours of 1-28-19. Staff #5 (RN) was asked to open the electronically locked medication cabinet. In the bottom of the cabinet there were 7 long, slender, clear, plastic containers for holding medications. Each container had a divider in the middle so you could put two different patient medications in the same container.

The following items were identified:

a. The first container had a patient's name marked in a permanent black marker on the outside. However, that patient had been discharged. Inside the container was a bottle of artificial tears with no patient label. On the outside of the eye medication was the patients first name and last name initial written with a black marker. There was no other identifying information.

b. The second and third containers had patient names, written in black marker, on the container. Those patients had been discharged and no longer in the facility. The third container held a nebulizer with a patient sticker. There was no name on the sticker only an admit date, time, date of birth, age of the patient, and the physician.

c. In the fourth container there were names written in black marker on the container that had been discharged. A sheet of paper was found in the container. The name on the paper was not the name on the container. The sheet was labeled "Individual Narcotic Count Sheet." The medication listed on the sheet was Testosterone. Testosterone is a hormone not a narcotic. The sheet had the patients name and "n/a" where it said "physician order." The patient was administered the drug on 11-1-18. The patient had been discharged in November but the sheet was still in the medication cabinet.

d. The fifth container had a patient label on the container but had another patient's contact lens in the container. Staff #5 confirmed the patients disposable contact box had been brought from home and had already been opened. The box was put in the medication cabinet where medications were stored. There was no evidence the box was intact and clean before entering the cabinet.

e. The seventh container had a patient name written that was no longer in the facility. A Styrofoam cup was found sitting in the container. The cup held 7 different tubes of chap stick. Six of the chap sticks were found to have patient stickers on them. One of the tubes just had a patient's first name on it. Staff #5 confirmed when the patient's needed chap stick they were allowed to use the stick on their mouths return it to the nurse and it was commingled with the other chap sticks. They were then placed back into the clean medication cabinet where it could possibly contaminate the other medications.

An interview was conducted with Staff #5 and Staff #6 on the morning of 1-28-19. Staff #5 stated that she could not tell me who the nebulizer belonged to. Staff #5 reported that she was not aware whose job it was to make sure the medication cabinet was cleaned. Staff #5 reported that when patients are discharged there is a box in the medication cabinet to put the medications left by those patients. The pharmacy was supposed to come and pick up those boxes. Staff #5 was unable to tell me who was supposed to watch for expired medications and remove them from the medication cabinet.

Staff #6(pharmacist) confirmed the nebulizer found in the medication cabinet was dispensed from the facility's pharmacy. Staff #6 reported the pharmacist is responsible for labeling these medications. Staff #6 was shown the nebulizer that was not labeled properly. Staff #6 was asked how the nurse administering the medication knew it was for the right patient with no name on it. Staff #6 confirmed there was no name on it but stated, "I can go and look who was here with that date of birth and tell you who it belonged to." Staff # 6 was asked if she was able, with no doubts, prove who the nebulizer belonged to and she responded, "I probably could but no I couldn't say for sure." Staff #6 reported that she was aware the chap sticks were in the medication cabinet and the contacts. Staff #6 reported that she checks the items coming in from home and didn't see it as an issue. Staff #6 was asked about the discharged patient medications and wrong labels with medications stored in the medication cabinet. Staff #6 confirmed the medications were supposed to be placed in the disposal box and was not aware of all the different labels. Staff #6 confirmed the pharmacy tech should be monitoring for discharged items and expired medications. Staff #6 confirmed that she was supposed to be monitoring the pharmacy technician.

Based upon record review and interview, the facility failed to ensure the Utilization Review (UR) Committee consisted of at least two members who were doctors of medicine or osteopathy.

Review of the "Utilization Review Plan" approved by the Governing Board on 1/23/2019, revealed the following:

"F. Organization and Composition of the Committee

1. Shall be a standing committee of the facility as described in this plan and approved by the
Governing Board.

2. The Chairperson will be the UR Director

3. Shall be composed of at least two (2) members ofthe active medical staff. Other members may
include:
Clinical Services
Nursing Service
Administrator (or representative)
Cf0 (or representative)
HIM Director
Therapists/Case Managers
Assessment and Referral Director (or representative)

4. Committee membership shall exclude all those persons who have a financial interest in the
facility. In addition, committee members who have been professionally involved in a case must
abstain from participating in the review ofthat case. A check of the medical record in advance
shall reveal which, if any, committee members should exclude themselves from the review
activities of any particular case.

During an interview with the UR Director (Staff #33) on 1/31/2019 at 11:00 am., the Director reported there were currently no physician participation in the UR Committee. The Director further reported that in the past, the Medical Director had participated in the UR Committee, but the Medical Director had resigned 2 months prior and the interim Medical Director had not been asked to participate. When questioned about other physicians being involved, the Director reported that all physicians are notified of committee meetings and invited to attend, however, none of the physicians had shown an interest.

Based on observation, interview and document review, the facility failed to dispose of trash appropriately.


Findings include:

An observation tour on 1/29/2019 with Staff #8 revealed the following:

On the outside dock, just through the exit door, a large uncovered trash container with multiple trash bags was noted. The portable trash container was overflowing with full trash bags and no cover over the top. This could result in rodent activity and the possible spread of disease. Empty multiple large and small trash cans were stacked together that appeared dirty. Staff #8 was asked if the trash cans were clean or dirty. Staff #8 said he did not know if the trash cans were clean or dirty. One large trash container was noted to have duct tape applied from the lid to the container. One rubber mat folded was lying on the ground next to the trash bin. Four boxes were placed on the ground in front of the large uncovered trash container. Staff #8 was asked, "Why were the trash and trash bins stored there." Staff #8 said, "The trash should have been placed in the dumpster around the corner." Staff #8 was asked who brought this out to the dock. Staff #8 said, "He did not know who or how long it had been there."

Staff #8 confirmed the findings.

Review of the facility policy titled, Environmental Cleaning, #1600.72, with a revised date of 1/17 revealed the following:

" ...K. Waste containers are lined with plastic bags that are discarded daily. The containers themselves will be washed at least once weekly or more often if they are obviously soiled. Liquids will not be poured into wastebaskets ..."

Based on record review and interview the facility failed to ensure:


1. A qualified candidate was appointed as the Infection Control Nurse.


This deficient practice had the likelihood to cause harm to all patients.


Findings include:


Review of Staff #10's personnel file revealed the following:

A. No signed Job Description for the position of Infection Control Officer.
B. No specialized training or certification in Infection Control.

Staff #4 and Staff #10 confirmed the findings.

An interview was conducted on 1/29/2019 after 1:00 PM with Staff #10. Staff #10 was asked about her infection control experience. Staff #10 said she did not have any experience related specifically to infection control.


2. Employee screening of TB testing was documented in a timely manner with the date and time read in 4 (Staff #6, Staff #25, Staff #34 and Staff #13) of 12 personnel files reviewed. There was no documentation of the time the TB test was read/resulted. 1 (Staff #11) of 12 personnel files reviewed did not indicate a current TB test.

Review of the 2019 Infection Prevention and Control Plan revealed the following:

" ...EMPLOYEE HEALTH RESPONSIBILITIES:
While the primary focus of the Infection Control Program at Facility is on patient care, the Infection Control Coordinator will conduct the following infection prevention activities for hospital employees and medical staff:
1. Annual flu immunizations
2. Annual tuberculosis testing ..."

Based on observation, document review, and interview the facility failed to ensure the Infection Control Plan was implemented, followed, and evaluated by the Infection Control Nurse.


This deficient practice had the likelihood to cause harm to all patients.


Findings include:

The Infection Prevention and Control Plan for 2019 was reviewed.


REVIEW OF THE Governing Body Committee Meeting held on January 23, 2019 revealed the following:

" ...AGENDA
XVII. Approval of IC plan, Risk assessments, Antimicrobial Stewardship policy and procedure ..."

The plan was previously reviewed and approved by The Medical Executive Committee on January 17, 2019.


An interview was conducted on 1/29/2019 after 1:00 PM with Staff #10. Staff #10 was asked about her infection control experience. Staff #10 said she did not have any experience related specifically to infection control
Review of Staff #10's personnel file revealed the following:

A. No signed Job Description for the position of Infection Control Officer.
B. No specialized training or certification in Infection Control.

Based on interview and record review, the facility failed to appoint a qualified MD/DO as director of respiratory care services.


This deficient practice had the likelihood to cause harm to all patients who required respiratory services at the facility.


Findings include:

An interview was conducted 1/29/2019 after 1:00 PM with Staff #2. Staff #2 was asked who was the medical director responsible for the respiratory services provided at the facility. Staff #2 stated, "Staff #14 was the medical director and he would also be the respiratory service director."

Review of Personnel #14's credential file revealed an application date of 1/02/2019. Personal #14's file did not contain any delineation of privileges for Medical Director of Respiratory Services or any date of appointment by the Medical Staff or Governing Body.

Staff #2 confirmed the above findings.

Based on interview and document review the facility failed to ensure respiratory services were delivered to all patients according to the facility policies and procedures.

This deficient practice had the likelihood to cause harm to all patients who required respiratory services at the facility.


Findings include:

An interview was conducted on 1/29/2019 after 1:00 PM with Staff #2. Staff #2 was asked if there were policies and procedures for respiratory services. Staff #2 said the policies for respiratory are located in the Clinical Services Policies but there are not any specific policies to a respiratory department.

Based on document review and interview, the facility failed to ensure staff providing respiratory services to patients were qualified and trained to provide the services


This deficient practice had the likelihood to cause harm to all patients who required respiratory services at the facility.

Findings include:

Review of the annual competency list for nursing staff revealed no specific training for the delivery of respiratory services to patients.

An interview was conducted on 1/29/2019 after 1:00 PM with Staff #2. Staff #2 was asked if the facility had a respiratory services department. Staff #2 said there was no organized respiratory services department. Staff #2 was asked if the hospital had respiratory therapist or techs on staff. Staff #2 said there are no Respiratory Therapist or respiratory therapy techs on staff.

Review of the facility employee list did not reveal any active fulltime, part time, temporary or PRN (as needed) Respiratory Therapist or respiratory therapy techs.

Based on observation, interview and record review the facility failed to ensure respiratory orders were documented in 1 (#32) of 1 patient's receiving respiratory care.


This deficient practice had the likelihood to cause harm to all patients who required respiratory services at the facility.


Findings include:

During observation on 1/30/2019 after 2:30 PM Staff #35 was seen writing a verbal order for Patient #32. Staff #35 was asked what the verbal order was written for. Staff #35 stated, "Patient #32's family was bringing his C-Pap (continuous positive airway pressure that forces air into the nasal passages) machine for him to use."

Review of facility policy titled, "Nasal Mask Ventilation", Policy and Procedure: 1000.105, with a revised date of 01/2019 revealed the following:

" ...A. check physician's order for prescribed EPAP, IPAP, Fi02 or CPAP levels ..."

Review of Patient #32's record revealed a verbal order was written by staff #32 for a "C-Pat" machine, but did not document the settings/levels of pressure for the machine.

Staff #35 confirmed the findings.